Luxury High Definition
DITA North America
Customer Account Number
*
Account Name
*
Customer Reference Number
Patient information is confirmed back to account, but is not received or retained by DITA. Please do not include patient PHI.
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submitted By
*
Contact Email
*
Frame Style and SKU
*
Lens Type
*
Please Select
Sun
Optical
Sun Lens Details
*
Optical Lens Details
*
Sun Lens Color
*
Optical Lens Color
*
Optional Flash Mirror
Please Select
No Flash Mirror
Gold Flash
Silver Flash
Blue Flash
Original LSARX Number
Reason for Redo
Rx Details
*
Rows
SPH
CYL
AXIS
ADD
PRISM
BASE
OD
OS
Measurements
*
Rows
DIST PD
NEAR PD
OC/SEG
OD
OS
Hight Lustre Edge Polish
*
Please Select
YES
NO
Authentic Engraving - OS
*
Please Select
YES
NO
Custom Engraving - OD
*
Please Select
YES
NO
Complimentary Custom Engraving
Limited to 15 characters (including spaces, letters and numbers). No special characters. Location top corner right lens.
Frame to Come
Please Select
NO
POF
OUT OF STOCK
Promo Code
.
Special Instructions
Contact us:
support@dita.com
+1 (888) 654-8145
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